Qualchoice.magellanrx.com
Magellan Rx Management
Provider Manual
Proprietary & Confidential
? 2014?2024 All rights reserved. Magellan Rx Management LLC, a Prime Therapeutics company
Table of Contents
1.0
1.1
2.0
2.1
2.2
2.3
2.4
2.5
2.6
3.0
3.1
3.2
4.0
4.1
4.2
4.3
5.0
5.1
5.2
5.3
6.0
6.1
6.2
7.0
7.1
7.2
8.0
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
Page 2
Introduction ..........................................................................................................................6
MRx Pharmacy Program .............................................................................................................. 6
Pharmacy Relations ...............................................................................................................7
Enrolling as an Approved Pharmacy ............................................................................................ 7
Credentialing and Quality Management ................................................................................... 22
Member Complaints .................................................................................................................. 25
Medication Error Reporting....................................................................................................... 25
Pharmacy Dispute Process ........................................................................................................ 25
Pharmacy Suspension Process .................................................................................................. 26
Billing Information ...............................................................................................................28
Claim Formats and Plan ¨C Specific Values ................................................................................. 28
Magellan Rx Management (MRx) Website Pharmacy Portal .................................................... 28
Call Center Services ..............................................................................................................29
Pharmacy Support Center ......................................................................................................... 29
Clinical Support Call Center ....................................................................................................... 29
Web Support Call Center ........................................................................................................... 29
Program Setup .....................................................................................................................30
Claim Format ............................................................................................................................. 30
Point-of-Sale ¨C NCPDP Version D.0 ........................................................................................... 30
Paper Claims .............................................................................................................................. 33
Service Support....................................................................................................................35
Online Certification ................................................................................................................... 35
Solving Technical Problems ....................................................................................................... 35
Online Claims Processing Edits .............................................................................................36
Paid, Denied, and Rejected Responses ..................................................................................... 36
Duplicate Response ................................................................................................................... 36
Program Specifications .........................................................................................................37
Timely Filing Limits .................................................................................................................... 37
Mandatory Generic Requirements ............................................................................................ 37
Dispensing Limits/Claim Restrictions ........................................................................................ 37
Provider Reimbursement .......................................................................................................... 38
Plan Co-Pays .............................................................................................................................. 39
Prior Authorizations .................................................................................................................. 39
ProDUR Drug Utilization Review ............................................................................................... 41
Retro DUR .................................................................................................................................. 44
Special Participant Conditions ................................................................................................... 46
Compound Claims...................................................................................................................... 46
|
Magellan Rx Management Provider Manual
8.11 Partial Fills ................................................................................................................................. 47
9.0
Coordination of Benefits ......................................................................................................49
9.1
COB General Instructions .......................................................................................................... 49
10.0 Appendix A: Plan D.0 Payer Specification ..............................................................................53
11.0 Appendix B: Point-of-Sale Reject Codes and Messages ..........................................................54
11.1 Version D.0 Reject Codes for Telecommunication Standard .................................................... 54
12.0 Appendix C: State Regulatory Requirements .........................................................................65
12.1 Medicare Part D......................................................................................................................... 65
12.2 Alabama ..................................................................................................................................... 81
12.3 Alaska......................................................................................................................................... 83
12.4 Arizona ....................................................................................................................................... 85
12.5 Arkansas .................................................................................................................................... 87
12.6 California ................................................................................................................................... 88
12.7 Colorado .................................................................................................................................... 97
12.8 Connecticut.............................................................................................................................. 102
12.9 Delaware.................................................................................................................................. 105
12.10 District of Columbia ................................................................................................................. 106
12.11 Florida ...................................................................................................................................... 107
12.12 Georgia .................................................................................................................................... 112
12.13 Hawaii ...................................................................................................................................... 114
12.14 Idaho ........................................................................................................................................ 115
12.15 Illinois....................................................................................................................................... 117
12.16 Indiana ..................................................................................................................................... 120
12.17 Iowa ......................................................................................................................................... 124
12.18 Kansas ...................................................................................................................................... 126
12.19 Kentucky .................................................................................................................................. 127
12.20 Louisiana .................................................................................................................................. 130
12.21 Maine....................................................................................................................................... 131
12.22 Maryland ................................................................................................................................. 133
12.23 Massachusetts ......................................................................................................................... 136
12.24 Michigan .................................................................................................................................. 138
12.25 Minnesota................................................................................................................................ 142
12.26 Mississippi ............................................................................................................................... 145
12.27 Missouri ................................................................................................................................... 147
12.28 Montana .................................................................................................................................. 152
12.29 Nebraska .................................................................................................................................. 154
12.30 Nevada ..................................................................................................................................... 161
12.31 New Hampshire ....................................................................................................................... 163
12.32 New Jersey............................................................................................................................... 165
12.33 New Mexico ............................................................................................................................. 172
Magellan Rx Management Provider Manual
|
Page 3
12.34 New York ................................................................................................................................. 175
12.35 North Carolina ......................................................................................................................... 188
12.36 North Dakota ........................................................................................................................... 191
12.37 Ohio ......................................................................................................................................... 192
12.38 Oklahoma ................................................................................................................................ 196
12.39 Oregon ..................................................................................................................................... 197
12.40 Pennsylvania ............................................................................................................................ 198
12.41 Rhode Island ............................................................................................................................ 202
12.42 South Carolina ......................................................................................................................... 204
12.43 South Dakota ........................................................................................................................... 205
12.44 Tennessee ................................................................................................................................ 207
12.45 Texas ........................................................................................................................................ 208
12.46 Utah ......................................................................................................................................... 213
12.47 Vermont................................................................................................................................... 214
12.48 Virginia ..................................................................................................................................... 217
12.49 Washington ............................................................................................................................. 223
12.50 West Virginia ........................................................................................................................... 227
12.51 Wisconsin ................................................................................................................................ 232
12.52 Wyoming ................................................................................................................................. 238
13.0 Appendix D: Magellan Rx Management (MRx) Account ....................................................... 239
13.1 Pharmacy Application and Agreement and Pharmacy Disclosure Form ................................. 239
13.2 Website Pharmacy Portal ........................................................................................................ 240
13.3 Pharmacy Support Center ....................................................................................................... 240
13.4 Clinical Support Center ............................................................................................................ 240
13.5 Web Support ........................................................................................................................... 241
13.6 Universal Claim Form .............................................................................................................. 241
13.7 Request a Contract for Extended Days¡¯ Supply Participation ................................................. 241
13.8 Pharmacy Contracts for Provider Reimbursement Rates........................................................ 241
13.9 Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration of
Edits ......................................................................................................................................... 241
13.10 Payer Specification Document ................................................................................................ 241
13.11 Contact Information ................................................................................................................ 242
14.0 Appendix E: Community Care Plan (CCP) ............................................................................. 243
14.1 Pharmacy Application and Agreement and Pharmacy Disclosure Form ................................. 243
14.2 Website Pharmacy Portal ........................................................................................................ 244
14.3 Pharmacy Support Center ....................................................................................................... 244
14.4 Clinical Support Center ............................................................................................................ 244
14.5 Web Support ........................................................................................................................... 244
14.6 Universal Claim Form .............................................................................................................. 244
14.7 Request a Contract for Extended Days¡¯ Supply Participation ................................................. 244
Page 4
|
Magellan Rx Management Provider Manual
14.8
14.9
Pharmacy Contracts for Provider Reimbursement Rates........................................................ 245
Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration of
Edits ......................................................................................................................................... 245
14.10 Payer Specification Document ................................................................................................ 245
14.11 Contact Information ................................................................................................................ 245
15.0 Appendix F: Medicare Part D Network ................................................................................ 247
15.1 Services .................................................................................................................................... 247
15.2 Claim Processing ...................................................................................................................... 247
15.3 Compliance with Legal Regulations ......................................................................................... 248
15.4 Pharmacy Help Desk ................................................................................................................ 249
15.5 Eligibility Validation ................................................................................................................. 249
15.6 Low Income Subsidy (LIS) Change in Status ............................................................................ 249
15.7 Disaster Declaration ................................................................................................................ 250
15.8 Best Available Evidence (BAE) ................................................................................................. 250
15.9 Medicare Part D Claims Adjustment ....................................................................................... 251
15.10 General Medicare Part D Submission Requirements for COB................................................. 251
15.11 Emergency Overrides .............................................................................................................. 252
15.12 Marketing ................................................................................................................................ 252
15.13 Tamper Resistant Pads ............................................................................................................ 252
15.14 Medication Error Reporting..................................................................................................... 252
15.15 Formulary Transition Fill Process ............................................................................................ 252
15.16 Reject Messaging for Part B versus Part D Drug Coverage Determination ............................. 254
15.17 End Stage Renal Disease (ESRD) Custom Reject Messaging .................................................... 254
15.18 Long Term Care Pharmacy Providers ...................................................................................... 255
15.19 Maximum Allowable Cost (MAC) ............................................................................................ 257
16.0 Appendix G: Discrepancy Code List ..................................................................................... 259
17.0 Definitions ......................................................................................................................... 267
Magellan Rx Management Provider Manual
|
Page 5
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- visit today
- go digital to save on your next prescription
- access your prescription history price a drug and more
- magellan rx precision formulary
- medical pharmacy program magellan rx bright health plan
- home delivery order form magellan rx management
- welcome to magellan rx management
- member portal guide
- medical pharmacy program magellan rx
- magellan rx management provider manual
Related searches
- getroman com reviews
- acurafinancialservices.com account management
- acurafinancialservices.com account ma
- getroman.com tv
- http cashier.95516.com bing
- http cashier.95516.com bingprivacy notice.pdf
- connected mcgraw hill com lausd
- education.com games play
- rushmorelm.com one time payment
- autotrader.com used cars
- b com 2nd year syllabus
- gmail.com sign in